“All her life, Roya has known that her life was inextricably linked with her mother's death. Within hours of her birth in a small village in rural Afghanistan, Roya's mother had bled to death.”

“She was one of the thousand women who die each day in childbirth. In addition, every year more than 7 million babies are stillborn or die shortly after birth – the majority from preventable conditions.”

The article goes on to say, "Fragile states", such as Afghanistan, need particular attention. The number of women who die in childbirth in conflict countries is almost double that of women in non conflict countries. Fifty per cent of under-fives who die, live in fragile states. Yet very little of the funding received by fragile states is long-term or predictable.”

Finally, Roya, who is a new midwife, says, “’I have always wanted to prevent women from going through what my mother faced,’ she says. ‘Midwifery is so important to reducing the mortality crisis. If mothers are healthy, a country is healthy and strong.’"

Powerful stuff.

My comment with the posting, a pretty off-handed comment at that, was, "Ironic, isn't it... that the rest of the world is craving midwives and here, women are UCing?"

A UC is an Unassisted (Child)Birtha birth with no midwife or other trained provider in attendance. This birthing choice is highly controversial and I've written nastily about it in the past. I'm really trying not to be so nasty anymore, but it's a distinct challenge. I cannot, however, stop talking about my views on UCs; hence this post which almost wrote itself as I read the original article.

A comment to my Facebook posting came in from my friend and midwife Colleen Scarlett. She says:

"It annoys me to no end, having been raised and having birthed in the developing world, to hear Western women glorify birth in the developing world or birth in pioneer days as proof we should 'trust birth'.

"Every time I hear someone say, 'What did women do 200 years ago?' I want to say, 'Well, they DIED. OFTEN.' If you have ever been to a cemetery in New England that has gravestones from the 16 and 1700's, you will see Old Farmer John's gravestone, interred at 70 years old, buried alongside his 5 or 6 wives, all dead in their 20's, oftentimes buried with their newborns.

"Or when I hear someone say, 'Women all over the world squat in the fields and get up and go back to work,' I cringe. First off, I don't know of any culture where women simply squat in the fields, birth, and get right back to work because that baby would have a dead or dying mother in a few hours. The real truth is, globally, where women birth without an attendant, it's because either there's very little value placed on her life, there's no money to pay for an attendant, they live too far away from an attendant, or the attendant doesn't carry hemostatic drugs. And in those countries, women go into their pregnancies and labours praying they don't, but expecting to, die."

Many/Most of us who birth in the Western World, unless we've been elsewhere for any length of time, cannot comprehend the luxury it is for women to say they want to UC. Constant refrains from UCers is the close proximity of hospitals in case something happens. Imagine if those hospitals were three hours away and you had to walk to it and they would only let you in if you had the money... all with a massive hemorrhage going on or a shoulder dystocia. Would you want a midwife in your village then? I'm betting yes.

Many definitions abound, including the root of the word, “with woman.”

Is the term “midwife” self-defined? Would a midwife be someone who attends births… having had training or not? What if the training is adequate for one part of the world, but not another? Could there be a universal definition of who a midwife is and what her skills should be?

I thought I’d focus on the World Health Organization’s definition since it seems most closely aligned to my own.

"The midwife: the international definition of the midwife, according to WHO, ICM (International Confederation of Midwives) and FIGO (the International Federation of Obstetricians and Gynaecologists) is quite simple: if the education programme is recognized by the government that licenses the midwife to practice, that person is a midwife (Peters 1995)."

Does that mean if the person doesn't have the education a government sanctions that the person is not a midwife? Hmmm... something to consider, right?

"Generally he or she is a competent caregiver in obstetrics, especially trained in the care during normal birth. However, there are wide variations between countries with respect to training and tasks of midwives. In many industrialized countries midwives function in hospitals under supervision of obstetricians. Usually this means that the care in normal birth is part of the care in the whole obstetric department, and thus subject to the same rules and arrangements, with little distinction between high-risk and low-risk pregnancies."

"The effect of the International Definition of the Midwife is to acknowledge that different midwifery education programmes exist. These include the possibility of training as a midwife without any previous nursing qualification, or "direct entry" as it is widely known. This form of training exists in many countries, and is experiencing a new wave of popularity, both with governments and with aspiring midwives (Radford and Thompson 1987). Direct entry to a midwifery programme, with comprehensive training in obstetrics and related subjects such as paediatrics, family planning, epidemiology etc. has been acknowledged as both cost-effective and specifically focused on the needs of childbearing women and their newborn."

There’s been discussion of whether peds, family planning or well-woman care is a part of midwifery. It seems WHO believes it is and I agree with that. I definitely know I could use more training/information in those areas. I look forward to my upcoming Anatomy & Physiology classes to aid in my increasing comprehension of the nuances of a woman’s body. I know some (CPM/LM) training programs spend time on these topics and I applaud this. I believe all schools should have comprehensive information and require experience in these areas.

“More important than the type of preparation for practice offered by any government is the midwife's competence and ability to act decisively and independently. For these reasons it is vital to ensure that any programme of midwifery education safeguards and promotes the midwives' ability to conduct most births, to ascertain risk and, where local need dictates, to manage complications of childbirth as they arise (Kwast 1995b, Peters 1995, Treffers 1995)."

I think these are phenomenal recommendations. I like, so much, that they understand that different locations will create different midwives.

One of my thoughts is that here in the United States, we see so many different cultures that it is really imperative that we learn as much as we can about them all. I am so glad when I hear midwifery schools talk about multi-cultural issues, but also hope they discuss the nuts and bolts aspects of diet choices, physical customs and the hierarchy of the family. I know that I learned the hard way that not all men are (or want to be!) a part of the birthing process.

I remember a dad who chose to sit in the reclining chair in the labor room, leaning back and snoozing. Judgmentally, I was angry at his lack of participation until a kind nurse took me aside and explained to me that in his culture, men were typically not anywhere near a woman in labor, so his being in the room was tremendous support for his wife. Once again, I had my veil of ethnocentricity pulled back, exposing me to ways that were not my own, but were/are just as valid nonetheless.

I adore what WHO says about midwifery. I encourage every midwife, midwifery supporter and every wanna-be midwife to read the entire text of “Care in Normal Birth: A Practical Guide.” Without knowing it, the words, beliefs and desires contained inside the text are exactly how I feel.

WHO acknowledges community midwives and stresses what type of education those midwives should be obtaining. A community midwife is a midwife who works outside of the hospital, but might work collaboratively with physicians. Sometimes, community midwives are far from any medical care and might be called on to perform skills some of us might never encounter. A community midwife is different than a Traditional Birth Attendant. TBA’s typically have very little training other than experience. It isn’t uncommon for a TBA to have learned her craft only through apprenticeship, many times female generational (grandmother to her daughter to her daughter).

WHO has a vested interest in midwives earning and retaining the respect of physicians around the world. In every crevice of the world, it is the physician that can save the life of the woman or baby who needs more care than a midwife can offer. Midwives need obstetricians. If only we could have more on our side. In a few places, OBs work beside midwives in a spirit of cohesiveness and collaboration; each profession respecting the others’ roles. I would love to see the same thing – and (idealistically) I believe it can be done. The more a midwife’s education level grows to look like something the medicos recognize, the higher the level of respect we will have. We are well on our way with MEAC-accredited schools and the homogenization of midwifery education.

I know that, for some (many?) homogenization seems a negative, even awful, but in our growing need for acceptance because of legislation and tightening rules, being alike can work towards our benefit. The definition of “midwife” becomes completely understood – in any context.

WHO says, “…the midwife appears to be the most appropriate and cost effective type of health care provider to be assigned to the care of normal pregnancy and normal birth, including risk assessment and the recognition of complications.” (From what I can decipher, the term “Direct-Entry Midwife” was changed to simply “Midwife” in 1995.)

Among the recommendations accepted by the General Assembly of the XIII World Congress of FIGO (International Federation of Gynaecology and Obstetrics) in Singapore 1991 (FIGO 1992) are the following:

• "To make (midwifery) more accessible to women in greatest need, each function of maternity care should be carried out at themost peripheral level at which it is feasible and safe."

I absolutely agree with this. I believe this is saying midwives should be the care providers for normal birth and obstetricians reserved for high risk pregnancies and births. You bet!

•"To make the most efficient use of available human resources, each function of maternity care should be carried out by the least trained persons able to provide that care safely and effectively."

To me, this speaks to the doctors, nurses and hospitals in our communities (and insurance companies?) that midwives need, if not deserve, support even though we/they might not be operating inside the hospital. Of course, this is if the first two points are being accomplished as well.

“These recommendations point to the midwife as the basic health care provider in obstetrics delivering care in small health centres, in villages and at home, and perhaps also in hospitals (WHO 1994). Midwives are the most appropriate primary health care provider to be assigned to the care of normal birth. However, in many developed and developing countries midwives are either absent or are present only in large hospitals where they may serve as assistants to the obstetricians.”

“…health care does not take place in isolation from political, economic and cultural realities…,’ so nursing and midwifery education and practice do not take place in isolation from the political, social, economic, environmental and cultural realities of the Member States; neither must they be seen in isolation from the various stages of health care reform and the dynamic nature, or otherwise, of progress.”

I think this is part of what I am saying… that in today’s environment, we need to have as much education as is possible. If more education is needed for LMs/CPMs, finding a way for that to occur is really important. The political climate for midwives is changing and we need to change with it in order to keep up – and stay alive!

Instead of arguing for mediocrity, let’s move forward towards more knowledge and experience.

“Likewise, nurses and midwives do not practise in isolation from their colleagues in the other health care professions. Although each profession contributes unique knowledge and skills to health promotion and the care of patients, there is a need for much more multidisciplinary and interdisciplinary work, in a spirit of recognition and respect for each others’ authority, responsibility, ability and unique contribution. Thus, nurses and midwives must be educated to take their full part as members of the multiprofessional health care team, sharing both in the decision-making and, when appropriate, in taking responsibility for leadership of the team and for the outcomes of the work of the team.”

And, sure! The medicos need to acknowledge this as well. I agree!

“In the face of fundamental health care reform the complex factors depicted in Figure 1 and the resulting social transformation, and because nursing and midwifery education and practice are at very different stages of development in the Member States, it is timely that the professions be proactive in preparing a WHO European Strategy for Nursing and Midwifery Education. This Strategy is intended to be applicable today, but it also looks ahead to the twenty-first century. Although the focus of the Strategy is on preparation for entry into the professions of nursing and midwifery, this education must be seen as the first step in a journey of lifelong professional learning. As research-based knowledge of nursing and midwifery education and practice grows, so all practising nurses and midwives must continue to learn throughout their professional lives – in some cases developing new knowledge for specialist nursing and midwifery practice, in others deepening their knowledge of an existing field of practice.”

In the “Purpose and Objectives of the Strategy,” WHO says, “…it is essential that the nursing and midwifery professions be committed to the need for change in nursing and midwifery education and practice, and that nurses and midwives themselves become more actively involved in the change process.”

One of the issues I have with non-CNM midwives (that I’ve not yet seen discussed) is the tendency to embrace statistics/news that encourages letting go of technology whereas if statistics or news encourages more technology or a more hands-on approach appears, it either evaporates into the ether or is discounted en toto.

For example, in my on-going discussion about midwifery education, several people have brought up the World Health Organization’s statements that a midwife “…appears to be the most appropriate and cost effective type of health care provider to be assigned to the care of normal pregnancy and normal birth, including risk assessment and the recognition of complications.

However, in October 2006, WHO strongly advised the Active Management of Third Stage of Labor (AMTSL), but I haven’t heard of community midwives adopting that stance at all! AMTSL includes giving a medication to contract the uterus (Pitocin, Methergine or Cytotec), delayed cord clamping, controlled cord traction and uterine massage after the placenta is born. This is counter to what most midwives (myself included) are inclined to do (except for the delayed cord clamping), but here, sitting in front of us for over a year, is extremely well-documented information that, as far as I can tell, midwives aren’t listening to.

When it came time to toss aside the bulb syringe, most of us didn’t hesitate. Even when the information came out that oxygen isn’t the be all and end all in the first minute of resuscitation – that seems to have been easier to let go of for many midwives. The DeLee causing more problems than it helps? It disappeared from birth kits everywhere. Again, these are procedures that were on the more-invasive side and I find it’s not so painful to let those go. But, picking UP procedures is another story.

Why do any of us hesitate to utilize the information we have for the health and safety of our clients? It seems to run counter to being an LM or a CPM, but perhaps looking at new information is a part of our jobs, yes? What I would love to know is how many non-CNM midwives even know about AMTSL – and then, how many utilize it. Do non-CNMs utilize the information regularly? What do you tell your clients about it? Do you have a consent form detailing the options for AMTSL versus physiological third stage?

(It would be great to know how many CNMs also utilize AMTSL. Is it hard to do it after being so hands-off during the labor and birth? Has it changed the way you “manage” or not-manage third stage? What do the back-up docs say about it? Did you find out the information when it initially came out? Did you change your behavior/actions overnight?)

For my clients, I think I’m going to print out the information and make it a discussion topic during prenatals. I like that WHO says they specifically used the word “offer” instead of “use” so women could have the option of saying no, they didn’t want to have active management. Informed Consent, right?

In a time when so many midwifery websites quote the World Health Organization’s stand on midwifery, I would like to see us embracing their definition of a midwife. How many people who quote the statement that midwives should be the first line of defense for normal births have actually read through the entire treatise? I hope midwives and birth advocates will now go and read through it and really listen to what it says about risk, back-up, what is normal, how to attend to a myriad of situations and how vital midwifery is in our world today.